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Chronic obstructive pulmonary disease (COPD) is characterised by chronic irreversible airflow obstruction. The condition comprises pathological changes in four different compartments of the lungs: Central airways, peripheral airways, lung parenchyma and pulmonary vasculature. Affected individuals have variable involvement of each compartment. The pathogenesis of the disease is multifactorial, involving inflammatory changes in the lung in response to exposure to noxious particles or gases. There is a subsequent remodelling and thickening of the airway wall as well as destruction of alveoli and enlargement of airspaces. The net result is airflow obstruction, air trapping and hyperinflation. These physiological changes result in the cardinal symptoms of COPD namely; shortness of breath, cough, wheeze and chronic sputum production. Cigarette smoking is the leading environmental risk factor for the development of the disease. Half (50 per cent) of smokers are affected in their lifetime. Genetic factors, occupational exposures and environmental exposures can cause and contribute to disease progression.
COPD is a major cause of morbidity and mortality worldwide. It is the fourth leading cause of death in the world, but is projected to be third by 2020. More than three million people died from the condition in 2012, 6 per cent of all documented deaths worldwide. COPD is also a major cause of chronic morbidity. Many people suffer symptomatically for many years. As well as respiratory symptoms there are a range of extra pulmonary complications, including sarcopaenia, vasculopathy and osteoporosis.
COPD rates are projected to increase in the coming decades because of continued exposure to risk factors in an ageing population. As a result the huge economic burden of treatment will also continue to increase. In the European Union, the total direct costs of respiratory disease are estimated to be about 6 per cent of the total annual healthcare budget. COPD accounts for 65 per cent (€38.6 billion) of this.
The largest contributor to COPD healthcare expenditure is hospitalisation. International studies indicate that although the average length of stay has decreased since 1972, admissions per 1,000 persons per year have increased in all age groups. Hospitalisation-related costs in COPD patients are much higher than in other cohorts ($5,409 vs $3,511 according to the National Medical Expenditure Study in the US). The total cost of COPD hospitalisations in Ireland was over €70 million in 2014, with an average hospital length of stay of 9.5 days per person. Avoiding hospitalisation in COPD patients, therefore, should be a priority of all healthcare providers. Unfortunately, Ireland is struggling to keep COPD patients out of hospital. The second report of the National Healthcare Quality Reporting System showed that Ireland had the highest hospitalisation rates for COPD of all OECD countries, with an average admission rate of 394.9 per 100,000 people. This is obviously concerning at a time when healthcare costs and hospital waiting lists are escalating.
So, how can Ireland decrease its rates of hospitalisation for COPD patients while at the same time ensuring patient safety and in fact improving treatment outcomes? The answer is multifaceted and is the responsibility of healthcare providers, Government policy-makers and patient advocates.
There are a number of pharmacological and non-pharmacological interventions proven to decrease hospital admissions in COPD cohorts. From a pharmacological perspective, bronchodilators and inhaled steroids have been proven in large clinical trials, such as FLAME, UPLIFT and TORCH, to reduce rates of COPD exacerbation by up to 25 per cent. The role of inhaled corticosteroids in maintenance therapy is an area of particular interest. While they have beneficial effects on exacerbation rates, they are associated with an increase risk of pneumonia. Identifying which patients may benefit has led to a search for a reliable biomarker. Peripheral blood eosinophil counts may serve this role although more work is required in this area.
Adherence rates to inhaler regimes are surprisingly low. The World Health Organisation (WHO) estimates that only 50 per cent of patients receiving long-term pharmacotherapy for chronic diseases are adherent to treatment. Adherence rates for COPD interventions vary from 22-78 per cent. One of the most important factors that influence adherence to inhaled medications is patient education and doctor-patient communication. It is therefore incumbent on healthcare providers in all care settings to support, education and provide training on inhaler technique and compliance. Older patients with cognitive issues or patients with comorbidities that restrict their movements, such as rheumatoid arthritis, may be particularly vulnerable to adherence problems.
Other important pharmacological interventions include yearly influenza vaccine, which has been proven to reduce the need for inpatient care in patients with COPD. Antibiotics and oral steroids should be judiciously used to manage exacerbations.
While there is clearly a role for pharmacotherapy in the prevention of exacerbation and hospitalisation, non-pharmacological therapies are just as important. Smoking cessation has established benefits on the rate of decline of lung function, chronic symptoms and the development of comorbidities. In addition, the beneficial effects of stopping smoking on exacerbation frequency and hospitalisation have been described. Again education on how to stop smoking and access to cessation services plays an important role in a process that many patients find extremely challenging.
Pulmonary rehabilitation is a multidisciplinary strategy to optimise symptom control, physical capacity and health-related quality-of-life. A mix of supervised exercise and education lasts up to six weeks. It has been shown to limit the physiological and psychological impact of the disease and reduce exacerbations. Programmes are available in a number of centres nationally and provide consistent results. Considerable scope remains to increase capacity in existing centres and develop new programmes elsewhere. Patients need support in understanding the benefits that can accrue. Reluctance to engage may be due to lack of time, transportation issues and often fear of being able to keep up.
COPD is characterised by repeated exacerbations managed at home or in hospital. Following an acute discharge, the 90-day re-admission rates are as high as 35 per cent. Frequent admissions are a predictor of increased mortality. Increased age, low FEV1, elevated dyspnoea scores and previous exacerbations are predictors of re-admission that can guide physicians when discharge planning and arranging follow-up. COPD outreach schemes can provide a ‘hospital at home’ to ensure that recently discharged patients are closely monitored to reduce inpatient stays and reduce risk of re-admission. Patients are generally followed for up to six weeks with multiple home visits and are provided with access to services, such as physiotherapy when needed. They provide patients with the reassurance that they can access care and specialist expertise at home as they require it.
The OECD report that placed Ireland at the top of the list for COPD hospital admission also stated that countries that had noted a reduction in their hospital admissions had improved the access and quality of their primary care services. This is of paramount importance if Ireland is going to effectively reduce the number of hospital admissions from COPD in the coming years. Primary care facilities need to be resourced with equipment and trained staff to manage increasing numbers of mild to moderate COPD exacerbations in the community. This includes access to diagnostic spirometry and imaging as well as nursing care and education for patients. Ideally, outreach support from hospital-based respiratory services would be increasingly available to general practice. Rapid specialist access, including streamlined referral criteria for severe cases and cases failing to respond to treatment at home, need to be expanded.
Only through a collaborative and supportive approach between primary care and hospital services can we hope to reduce the number of COPD patients coming through the doors of the emergency department.
References on request